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Mandorfer M, Aigner E, Cejna M, Ferlitsch A, Datz C, Gräter T, Graziadei I, Gschwantler M, Hametner-Schreil S, Hofer H, Jachs M, Loizides A, Maieron A, Peck-Radosavljevic M, Rainer F, Scheiner B, Semmler G, Reider L, Reiter S, Schoder M, Schöfl R, Schwabl P, Stadlbauer V, Stauber R, Tatscher E, Trauner M, Ziachehabi A, Zoller H, Fickert P, Reiberger T. Austrian consensus on the diagnosis and management of portal hypertension in advanced chronic liver disease (Billroth IV). Wien Klin Wochenschr 2023:10.1007/s00508-023-02229-w. [PMID: 37358642 DOI: 10.1007/s00508-023-02229-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 05/15/2023] [Indexed: 06/27/2023]
Abstract
The Billroth IV consensus was developed during a consensus meeting of the Austrian Society of Gastroenterology and Hepatology (ÖGGH) and the Austrian Society of Interventional Radiology (ÖGIR) held on the 26th of November 2022 in Vienna.Based on international recommendations and considering recent landmark studies, the Billroth IV consensus provides guidance regarding the diagnosis and management of portal hypertension in advanced chronic liver disease.
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Affiliation(s)
- Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.
| | - Elmar Aigner
- First Department of Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Manfred Cejna
- Department of Radiology, LKH Feldkirch, Feldkirch, Austria
| | - Arnulf Ferlitsch
- Department of Internal Medicine I, KH Barmherzige Brüder Wien, Vienna, Austria
| | - Christian Datz
- Department of Internal Medicine, General Hospital Oberndorf, Teaching Hospital of the Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Tilmann Gräter
- Department of Radiology, Medical University of Graz, Graz, Austria
| | - Ivo Graziadei
- Department of Internal Medicine, KH Hall in Tirol, Hall, Austria
| | - Michael Gschwantler
- Division of Gastroenterology and Hepatology, Department of Medicine IV, Klinik Ottakring, Vienna, Austria
| | - Stephanie Hametner-Schreil
- Department of Gastroenterology and Hepatology, Ordensklinikum Linz Barmherzige Schwestern, Linz, Austria
| | - Harald Hofer
- Department of Internal Medicine I, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Mathias Jachs
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Alexander Loizides
- Department of Radiology, Medical University of Innbsruck, Innsbruck, Austria
| | - Andreas Maieron
- Department of Internal Medicine II, University Hospital St. Pölten, St. Pölten, Austria
| | - Markus Peck-Radosavljevic
- Department of Internal Medicine and Gastroenterology, Hepatology, Endocrinology, Rheumatology and Nephrology, Klinikum Klagenfurt am Wörthersee, Klagenfurt, Austria
| | - Florian Rainer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Bernhard Scheiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Georg Semmler
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Lukas Reider
- Department of Interventional Radiology, Medical University of Vienna, Vienna, Austria
| | - Silvia Reiter
- Department of Internal Medicine and Gastroenterology and Hepatology, Kepler Universitätsklinikum, Linz, Austria
| | - Maria Schoder
- Department of Interventional Radiology, Medical University of Vienna, Vienna, Austria
| | - Rainer Schöfl
- Department of Gastroenterology and Hepatology, Ordensklinikum Linz Barmherzige Schwestern, Linz, Austria
| | - Philipp Schwabl
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Vanessa Stadlbauer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Rudolf Stauber
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Elisabeth Tatscher
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Alexander Ziachehabi
- Department of Internal Medicine and Gastroenterology and Hepatology, Kepler Universitätsklinikum, Linz, Austria
| | - Heinz Zoller
- Department of Internal Medicine I, Medical University of Innsbruck, Innsbruck, Austria
| | - Peter Fickert
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.
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Identifying characteristics of drug-related problems in critically ill patients with decompensated liver cirrhosis. Eur J Gastroenterol Hepatol 2019; 31:1569-1576. [PMID: 31464786 DOI: 10.1097/meg.0000000000001492] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Characteristics of drug-related problems and related patient harm has not been evaluated in critically ill patients with decompensated cirrhosis. Our objectives were to identify characteristics and incidence rate of drug-related problems and related preventable harm in critically ill patients with decompensated liver cirrhosis. PATIENTS AND METHODS A prospective observational study was conducted from February 2018 to January 2019 in 10-bed medical intensive care unit of a tertiary care hospital. Medication charts of 78 patients diagnosed with decompensated cirrhosis were reviewed by the clinical pharmacist. Pharmaceutical care-related standard tools were applied for classification of drug-related problems and their severity of outcomes. RESULTS A total of 394 drug-related problems with an incidence rate of 298.48 per 1000 patient medical intensive care unit-day were identified. Most common drug-related problems were drug-drug interaction (48.7%) followed by guideline nonconformity (15.5%), inappropriate drug form (11.9%), and contraindication (9.6%). Approximately 27% of drug-related problems induced preventable harm, which included temporary harm (19.8%), permanent harm (5.8%), and death (0.8%). The incidence rate of preventable harm was found to be 78.78 per 1000 patient medical intensive care unit-day. Nonsteroidal anti-inflammatory drugs were the most common medications involved in drug-drug interaction, guideline nonconformity, and contraindication which led to gastrointestinal bleeding (24%) and worsening of renal function (11.5%). CONCLUSION Drug-related problems occurred commonly in critically ill patients with decompensated liver cirrhosis and induced preventable harm which jeopardized the safety of these vulnerable patients. Clinical pharmacist's intervention is essential for identification of drug-related problems and related preventable harm among these patients.
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Affiliation(s)
- David H Ellison
- Departments of Medicine and Physiology and Pharmacology, Oregon Health & Science University, Portland, Oregon; and Renal Section, Veterans Affairs Portland Health Care System, Portland, Oregon
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Austrian consensus guidelines on the management and treatment of portal hypertension (Billroth III). Wien Klin Wochenschr 2017; 129:135-158. [PMID: 29063233 PMCID: PMC5674135 DOI: 10.1007/s00508-017-1262-3] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 08/22/2017] [Indexed: 12/14/2022]
Abstract
The Billroth III guidelines were developed during a consensus meeting of the Austrian Society of Gastroenterology and Hepatology (ÖGGH) and the Austrian Society of Interventional Radiology (ÖGIR) held on 18 February 2017 in Vienna. Based on international guidelines and considering recent landmark studies, the Billroth III recommendations aim to help physicians in guiding diagnostic and therapeutic strategies in patients with portal hypertension.
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Rogers NA, Gupta S, Cuthbert JA. Continuous furosemide infusion in the management of ascites. J Investig Med 2014; 60:671-5. [PMID: 22373660 DOI: 10.2310/jim.0b013e31824963f1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND The current therapy for patients hospitalized with ascites requires titration of oral diuretics and often needs several days. A faster method for predicting the response to a given dose of diuretic may allow this process to be completed more rapidly. AIM The objective of this study was to describe the short-term safety and efficacy of a diuretic infusion to predict net sodium excretion in patients with cirrhosis, ascites, and edema using a fractional excretion of sodium (FENa) of 1% or greater as the target. METHODS We conducted a retrospective case series of patients admitted for management of ascites who received intravenous furosemide by continuous infusion in ascites management. Patients were stratified depending on whether they had edema or received an intravenous bolus of furosemide or a large-volume paracentesis. The primary outcome was the proportion of patients achieving a FENa of 1% or greater during the infusion. Secondary outcomes included development of electrolyte abnormalities or acute kidney injury during or immediately following the infusion and natriuresis on titrated oral furosemide. RESULTS Forty-seven patients meeting criteria were identified from 721 patients seen in consultation. Ten of the patients had edema and received neither bolus intravenous diuretic therapy nor therapeutic paracentesis; all 10 achieved a FENa of 1% or greater. One patient had transient hypokalemia. Of 37 patients who either had no edema or received additional treatment options, all but 6 patients achieved a FENa of 1% or greater. Transient complications in 31 patients with natriuresis included hyponatremia (n = 1), hypokalemia (n = 5), and acute kidney injury (n = 3). Twenty-four-hour urine sodium averaged more than 4 g/d on the titrated oral furosemide regimen in 19 patients completing the collection. CONCLUSIONS Use of a short continuous furosemide infusion can achieve a FENa of 1% or greater in patients with cirrhotic ascites and may be safe and efficacious for diuresis, meriting further study.
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Affiliation(s)
- Nicholas A Rogers
- Parkland Memorial Hospital, Parkland Health and Hospital System, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, USA
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Biecker E. Diagnosis and therapy of ascites in liver cirrhosis. World J Gastroenterol 2011; 17:1237-48. [PMID: 21455322 PMCID: PMC3068258 DOI: 10.3748/wjg.v17.i10.1237] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2010] [Revised: 12/22/2010] [Accepted: 12/29/2010] [Indexed: 02/06/2023] Open
Abstract
Ascites is one of the major complications of liver cirrhosis and is associated with a poor prognosis. It is important to distinguish noncirrhotic from cirrhotic causes of ascites to guide therapy in patients with noncirrhotic ascites. Mild to moderate ascites is treated by salt restriction and diuretic therapy. The diuretic of choice is spironolactone. A combination treatment with furosemide might be necessary in patients who do not respond to spironolactone alone. Tense ascites is treated by paracentesis, followed by albumin infusion and diuretic therapy. Treatment options for refractory ascites include repeated paracentesis and transjugular intrahepatic portosystemic shunt placement in patients with a preserved liver function. Potential complications of ascites are spontaneous bacterial peritonitis (SBP) and hepatorenal syndrome (HRS). SBP is diagnosed by an ascitic neutrophil count > 250 cells/mm3 and is treated with antibiotics. Patients who survive a first episode of SBP or with a low protein concentration in the ascitic fluid require an antibiotic prophylaxis. The prognosis of untreated HRS type 1 is grave. Treatment consists of a combination of terlipressin and albumin. Hemodialysis might serve in selected patients as a bridging therapy to liver transplantation. Liver transplantation should be considered in all patients with ascites and liver cirrhosis.
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Kalambokis G, Tsianos EV. Midodrine and furosemide-induced natriuresis in cirrhotics with ascites. Aliment Pharmacol Ther 2011; 33:415-6. [PMID: 21198702 DOI: 10.1111/j.1365-2036.2010.04536.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Kim YS. [Ascites, hepatorenal syndrome and spontaneous bacterial peritonitis in patients with portal hypertension]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2010; 56:168-85. [PMID: 20847607 DOI: 10.4166/kjg.2010.56.3.168] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Ascites, hepatic encephalopathy and variceal hemorrhage are three major complications of portal hypertension. The diagnostic evaluation of ascites involves an assessment of its etiology by determining the serum-ascites albumin gradient and the exclusion of spontaneous bacterial peritonitis. Ascites is primarily related to an inability to excrete an adequate amount of sodium into urine, leading to a positive sodium balance. Sodium restriction and diuretic therapy are keys of ascites control. But, with the case of refractory ascites, large volume paracentesis and transjugular portosystemic shunts are required. In hepatorenal syndrome, splanchnic vasodilatation with reduction in effective arterial volume causes intense renal vasoconstriction. Splanchnic and/or peripheral vasoconstrictors with albumin infusion, and renal replacement therapy are only bridging therapy. Liver transplantation is the only definitive modality of improving the long term prognosis.
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Affiliation(s)
- Young Seok Kim
- Department of Internal Medicine, Bucheon Hospital, Soon Chun Hyang University College of Medicine, Bucheon, Korea.
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Abstract
Ascites is the pathologic accumulation of fluid in the peritoneal cavity and is a common manifestation of liver failure, being one of the cardinal signs of portal hypertension. The diagnostic evaluation of ascites involves an assessment of its cause by determining the serum-ascites albumin gradient and the exclusion of complications eg, spontaneous bacterial peritonitis. Although sodium restriction and diuretics remain the cornerstone of ascites management, many patients require additional therapy when they become refractory to such medical treatment. These include repeated large volume paracentesis and transjugular intrahepatic portosystemic shunts. This review article summarizes diagnostic tools and provides an evidence-based approach to the management of ascites.
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Affiliation(s)
- Wei Hou
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, MCV Box 980341, Richmond, VA 23298-0341, USA
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Affiliation(s)
- Bruce A Runyon
- Liver Service, Loma Linda University Medical Center, Loma Linda, CA 92354, USA.
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Assy N, kayal M, Mejirisky Y, Gorenberg M, Hussein O, Schlesinger S. The changes in renal function after a single dose of intravenous furosemide in patients with compensated liver cirrhosis. BMC Gastroenterol 2006; 6:39. [PMID: 17134488 PMCID: PMC1702545 DOI: 10.1186/1471-230x-6-39] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2006] [Accepted: 11/29/2006] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Patients with compensated Child-A cirrhosis have sub clinical hypovolemia and diuretic treatment could result in renal impairment. AIM To evaluate the changes in renal functional mass as reflected by DMSA uptake after single injection of intravenous furosemide in patients with compensated liver cirrhosis. METHODS Eighteen cirrhotic patients were divided in two groups; eight patients (group 1, age 56 +/- 9.6 yrs, Gender 5M/3F, 3 alcoholic and 5 non alcoholic) were given low intravenous 40 mg furosemide and ten other patients (group 2, age 54 +/- 9.9, Gender 6M/4F, 4 alcoholic and 6 non alcoholic) were given high 120 mg furosemide respectively. Renoscintigraphy with 100MBq Of Tc 99 DMSA was given intravenously before and 90 minutes after furosemide administration and SPECT imaging was determined 3 hours later. All patients were kept under low sodium diet (80mEq/d) and all diuretics were withdrawn for 3 days. 8-hours UNa exertion, Calculated and measured Creatinine clearance (CCT) were performed for all patients. RESULTS Intravenous furosemide increased the mean renal DMSA uptake in 55% of patients with compensated cirrhosis and these changes persist up to three hours after injection. This increase was at the same extent in either low or high doses of furosemide. (From 12.8% +/- 3.8 to 15.2% +/- 2.2, p < 0.001 in Gr I as compared to 10.6% +/- 4.6 to 13.5% +/- 3.6 in Gr 2, p < 0.001). In 8 patients (45%, 3 pts from Gr 1 and 5 pts from Gr 2) DMSA uptake remain unchanged. The mean 8 hrs UNa excretion after intravenous furosemide was above 80 meq/l and was higher in Gr 2 as compared to Gr 1 respectively (136 +/- 37 meq/l) VS 100 +/- 36.6 meq/l, P = 0.05). Finally, basal global renal DMSA uptake was decreased in 80% of patients; 22.5 +/- 7.5% (NL > 40%), as compared to normal calculated creatinine clearance (CCT 101 +/- 26), and measured CCT of 87 +/- 30 cc/min (P < 0.001). CONCLUSION A single furosemide injection increases renal functional mass as reflected by DMSA in 55% of patients with compensated cirrhosis and identify 45% of patients with reduced uptake and who could develop renal impairment under diuretics. Whether or not albumin infusion exerts beneficial effect in those patients with reduced DMSA uptake remains to be determined.
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Affiliation(s)
- Nimer Assy
- Liver Unit, Sieff Hospital, Safed, Israel
- Department of Internal Medicine A, Sieff Hospital, Safed, Israel
- Faculty of Medicine, Technion Institute of Technology, Haifa, Israel
| | - Mohib kayal
- Department of Internal Medicine B, Sieff Hospital, Safed, Israel
| | - Yoram Mejirisky
- Department of Internal Medicine B, Sieff Hospital, Safed, Israel
| | | | - Osamah Hussein
- Department of Internal Medicine A, Sieff Hospital, Safed, Israel
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Chalasani N, Gorski JC, Horlander JC, Craven R, Hoen H, Maya J, Brater DC. Effects of albumin/furosemide mixtures on responses to furosemide in hypoalbuminemic patients. J Am Soc Nephrol 2001; 12:1010-1016. [PMID: 11316860 DOI: 10.1681/asn.v1251010] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Hypoalbuminemic patients often have sufficient fluid accumulation to mandate diuretic therapy but are often resistant to diuresis. Studies have suggested that hypoalbuminemia itself impairs delivery of effective amounts of diuretic agent into the urine, the site of action. Therefore, administration of mixtures of albumin and loop diuretics may enhance responses. Thirteen patients with biopsy-proven cirrhosis and ascites (age, 51.2 +/- 8.1 yr; Child-Pugh score, 8.5 +/- 1.0; serum albumin concentration, 3.0 +/- 0.6 g/dl) were studied in this randomized crossover study. Sodium balance was maintained throughout the study with a metabolic diet. All patients received spironolactone, but administration of all other diuretic agents was discontinued. Each patient received all of the following four treatments intravenously: (1) 40 mg of furosemide, (2) 25 g of albumin, (3) 40 mg of furosemide and 25 g of albumin premixed ex vivo, and (4) 40 mg of furosemide and 25 g of albumin infused simultaneously into different arms. Responses were assessed by measuring urinary sodium excretion and relating the urinary furosemide excretion rate to the sodium excretion rate. Additionally, the pharmacokinetics of furosemide were assessed. Furosemide pharmacokinetics were similar for all treatment arms. Albumin alone had negligible diuretic effects. Neither albumin regimen increased the response to furosemide. Moreover, the relationship between the urinary furosemide excretion rate and the sodium excretion rate was unaffected by albumin. In conclusion, albumin failed to enhance the diuretic effects of furosemide in cirrhotic patients with ascites. Therefore, the coadministration of albumin and furosemide for the treatment of cirrhosis, and likely other hypoalbuminemic conditions, should not be used clinically.
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Affiliation(s)
- Naga Chalasani
- Division of Gastroenterology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - J Christopher Gorski
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - John C Horlander
- Division of Gastroenterology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Rebecca Craven
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Helena Hoen
- Division of Biostatistics, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Juan Maya
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - D Craig Brater
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
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Abstract
The evaluation of ascites includes a directed history, focused physical examination, and diagnostic paracentesis with ascitic fluid analysis. Dietary sodium restriction and oral diuretics are the mainstay of therapy for the majority of patients with cirrhotic ascites. Transjugular intrahepatic portocaval shunt has emerged as the treatment of choice for selected patients with refractory ascites, although serial large-volume paracenteses should be attempted first. Early diagnosis, broad-spectrum antibiotics, and albumin infusion contribute to the successful management of spontaneous bacterial peritonitis (SBP). Referral for liver transplant evaluation should be considered at the first sign of decompensation and should not be delayed until development of ominous clinical features, such as refractory ascites and SBP.
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Affiliation(s)
- A S Yu
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, and Liver Transplant Program, Stanford University Medical Center, Stanford, USA.
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Abstract
Ascites is the most common of the major complications of cirrhosis. The development of ascites is an important landmark in the natural history of cirrhosis and has been proposed as an indication for liver transplantation. The initial evaluation of a patient with ascites should include a history, physical evaluation, and abdominal paracentesis with ascitic fluid analysis. Treatment should consist of abstinence from alcohol, sodium restricted diet, and diuretics. This regimen is effective in approximately 90% of patients. The treatment options for the diuretic-resistant patients include serial therapeutic paracenteses, liver transplantation, and peritoneovenous shunting.
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Affiliation(s)
- B A Runyon
- Loma Linda Transplantation Institute, CA 92354, USA
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Affiliation(s)
- B A Runyon
- Department of Internal Medicine, University of Iowa College of Medicine, Iowa City
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Quiroga J, Zozaya JM, Labarga P, Rodríguez-Ortigosa CM, Milazzo A, Prieto J. Renal prostacyclin influences renal function in non-azotemic cirrhotic patients treated with furosemide. J Hepatol 1991; 12:170-5. [PMID: 2050996 DOI: 10.1016/0168-8278(91)90934-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The influence of prostaglandins on renal function changes induced by furosemide was analyzed in 21 non-azotemic cirrhotic patients with ascites. Patients were studied in two periods of 120 min immediately before and after furosemide infusion (20 mg, ev). Furosemide caused an increase in creatinine clearance in 15 patients (group A: 99 +/- 7 vs. 129 +/- 5 ml/min; mean +/- S.E.) and a reduction in the remaining six (group B: 102 +/- 13 vs. 71 +/- 9 ml/min). Parallel changes were observed in the urinary excretion of 6-Keto-prostaglandin-F1 alpha (metabolite of renal prostacyclin) which augmented after furosemide in 14 of the 15 patients from group A (478 +/- 107 vs. 1034 +/- 159 pg/min, p less than 0.001) and decreased in all patients from group B (1032 +/- 240 vs. 548 +/- 136 pg/min, p less than 0.05). In contrast, the urinary excretion of prostaglandin E2 was stimulated by furosemide in all patients (group A, 92 +/- 19 vs. 448 +/- 60 pg/min, p less than 0.001; and group B, 209 +/- 63 vs. 361 +/- 25 pg/min, p less than 0.05). In all of the patients furosemide-induced changes (post- minus pre-furosemide values) in creatinine clearance were closely correlated in a direct and linear fashion with those in 6-Keto-prostaglandin-F1 alpha (r = 0.74; p less than 0.001). These changes were associated with a higher furosemide-induced natriuresis in group A than in group B (641 +/- 68 vs. 302 +/- 46 mumol/min, p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- J Quiroga
- Department of Internal Medicine, University Clinic of Navarra, Pamplona, Spain
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Affiliation(s)
- B D Rose
- Brigham and Women's Hospital, Boston, Massachusetts
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Dixon MF. Progress in the pathology of gastritis and duodenitis. CURRENT TOPICS IN PATHOLOGY. ERGEBNISSE DER PATHOLOGIE 1990; 81:1-40. [PMID: 2407435 DOI: 10.1007/978-3-642-74662-8_1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Cereda JM, Roulot D, Braillon A, Moreau R, Koshy A, Lebrec D. Reduction of portal pressure by acute administration of furosemide in patients with alcoholic cirrhosis. J Hepatol 1989; 9:246-51. [PMID: 2809166 DOI: 10.1016/0168-8278(89)90058-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
In patients with cirrhosis, it has been demonstrated that blood volume and degree of portal hypertension are correlated. Hence, a reduction of blood volume by furosemide could decrease portal pressure and could thereby be useful in the treatment of portal hypertension. Splanchnic and systemic haemodynamics were evaluated before and 1 h after intravenous administration of furosemide (0.75 mg/kg) in 10 patients with cirrhosis. Furosemide significantly increased haemoglobin from 12.4 to 13.0 g/dl and patients passed more than 1 l of urine within the 3 h following furosemide administration. These findings confirm that blood volume decreased after diuretic administration. Cardiac output significantly decreased from 6.6 +/- 2.3 to 5.5 +/- 2.2 l/min, while arterial pressure and heart rate did not change significantly. Furosemide significantly decreased wedged hepatic venous pressure from 31.1 +/- 6.2 to 27.7 +/- 5.2 mmHg, but not free hepatic venous pressure. Accordingly, the hepatic venous pressure gradient significantly decreased from 22.1 +/- 5.4 to 19.5 +/- 4.0 mmHg. Azygos blood flow and hepatic blood flow also significantly decreased from 0.40 +/- 0.17 to 0.31 +/- 0.13 l/min and from 1.49 +/- 0.50 to 0.82 +/- 0.30 l/min, respectively. These results show that diuretic therapy markedly influences splanchnic haemodynamics.
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Affiliation(s)
- J M Cereda
- Unité de Recherches de Physiopathologie Hépatique (INSERM U-24), Hôpital Beaujon, Clichy, France
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23
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Smith AC. Duodenal ulcer disease: what role does Campylobacter pylori play? SCANDINAVIAN JOURNAL OF GASTROENTEROLOGY. SUPPLEMENT 1989; 160:14-8. [PMID: 2683020 DOI: 10.3109/00365528909091729] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Duodenal ulcer is a chronic relapsing condition which only became common early this century. Many pathogenic factors have been identified including excess gastric acid secretion, cigarette smoking, non-steroidal anti-inflammatory drugs and reduced mucosal defence. There is a strong association of duodenal ulceration, gastric Campylobacter pylori and antral (type-B) gastritis. The link between ulceration in the duodenum and C. pylori-associated antral gastritis may lie in the formation of gastric-type epithelium in the duodenum (gastric metaplasia). This metaplastic tissue is susceptible to C. pylori colonization and therefore to the local effects of these bacteria. Several reports suggest that duodenal ulcer relapse is more frequent in patients infected with C. pylori. These data are reviewed and a brief history of duodenal ulcer disease is presented.
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Affiliation(s)
- A C Smith
- Dept. of Gastroenterology, Northwick Park Hospital, Harrow, London, U.K
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24
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Tytgat GN. Campylobacter pylori: epidemiological considerations. SCANDINAVIAN JOURNAL OF GASTROENTEROLOGY. SUPPLEMENT 1989; 160:1-2. [PMID: 2814344 DOI: 10.3109/00365528909091726] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- G N Tytgat
- Academic Medical Centre, Division of Gastroenterology/Hepatology, Amsterdam, The Netherlands
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25
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Wormsley KG. Campylobacter pylori and ulcer disease--a causal connection? SCANDINAVIAN JOURNAL OF GASTROENTEROLOGY. SUPPLEMENT 1989; 160:53-8. [PMID: 2683023 DOI: 10.3109/00365528909091736] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
A strong positive correlation has been demonstrated between the (antral mucosal) presence of Campylobacter pylori and active duodenal and gastric ulceration. Moreover, both duodenal and gastric ulcers heal, and remain in remission, as a consequence of therapeutic measures which eradicate C. pylori. However, the Henle-Koch postulates have not been fulfilled, because C. pylori has not been shown to produce ulcers. As for the claim that ulcer disease represents an infection with C. pylori because therapeutic eradication heals ulcers, it has been shown that antibiotics and metronidazole, as well as bismuth subcitrate, exert antiulcer actions by mechanisms which do not involve their antibacterial effects. The association between C. pylori and ulcer disease, which was noted half a century ago, remains unexplained now as it did then.
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Affiliation(s)
- K G Wormsley
- Ninewells Hospital and Medical School, Dundee, Scotland
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26
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Gentilini P, Laffi G, Meacci E, La Villa G, Cominelli F, Pinzani M, Buzzelli G. Effects of OKY 046, a thromboxane-synthase inhibitor, on renal function in nonazotemic cirrhotic patients with ascites. Gastroenterology 1988; 94:1470-7. [PMID: 3360268 DOI: 10.1016/0016-5085(88)90688-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
To assess the possible role of increased renal thromboxane A2 (TXA2) synthesis in nonazotemic patients with cirrhosis and ascites and to establish the potential beneficial effect of inhibitors of renal TXA2 production in this clinical setting, we administered OKY 046, a selective TXA2 synthase inhibitor, 200 mg t.i.d. for 5 days, to 9 nonazotemic cirrhotic patients with ascites and avid sodium retention. OKY 046 inhibited platelet TXA2 production, as expressed by serum thromboxane B2 (TXB2) concentration, by approximately 85% (p less than 0.001 vs. baseline values) and reduced urinary TXB2 excretion by 72% (p less than 0.01). A significant increase of approximately 19% in inulin clearance was observed during the treatment (from 61.0 +/- 8.42 to 72.7 +/- 7.45 ml/min, p less than 0.05), whereas renal blood flow was unchanged (from 408.50 +/- 19.97 to 424.50 +/- 30.84 ml/min). Drug administration did not affect positive sodium balance [sodium excretion was 4.67 +/- 1.22 mEq/day before drug administration and 6.26 +/- 1.05 mEq/day during drug administration (on day 7)], plasma renin activity, plasma aldosterone concentration, or the urinary excretion of prostaglandin E2, 6-keto prostaglandin F1 alpha, or prostaglandin F2 alpha. These results suggest that renal TXA2 synthesis contributes to the regulation of renal hemodynamics in nonazotemic cirrhotic patients with ascites and avid sodium retention, but it does not seem to affect sodium balance.
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Affiliation(s)
- P Gentilini
- Clinica Medica II, University of Florence School of Medicine, Italy
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